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Rhinoplasty: breathe better, look better

August 27, 2013

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In Hollywood and in your neighborhood, the "nose job" -- or rhinoplasty, in medical terms -- has become more commonplace and less scandalous. Though constant media exposure has reduced its risks in the mindset of Americans, rhinoplasty is still surgery with significant effects, beyond the mere cosmetic. We asked plastic surgeon Jeffrey R. Marcus, MD, a pediatric plastic surgeon at Duke for his input on the risks and benefits and do's and don'ts of rhinoplasty.

How common is rhinoplasty?

According to the American Society of Plastic Surgeons, rhinoplasty is now the third most common cosmetic procedure performed in the United States, behind only breast augmentation and liposuction. Among adolescents, ages 13 through 19, it is the most common plastic surgical procedure overall.

Though the numbers of surgeries performed are high, plastic surgeons consistently describe rhinoplasty among the most challenging procedures to perform. In fact, many plastic surgeons choose not to perform rhinoplasty. Therefore, relative to other procedures, a smaller number of surgeons perform a large proportion of rhinoplasties.

It is important for anyone seeking rhinoplasty to understand that it is actually different from other plastic surgery procedures, due to the complex function of the nose, the cosmetic significance of the nose, and the technical challenges for the surgeon.

Why do people ask for the procedure?

People seek nasal surgery for several reasons: some have concerns only related to appearance, while others have functional problems, such as nasal obstruction. Some may have both.

What many people may not appreciate is that in the nose, form and function are intimately linked. A cosmetic change in the structure of the nose can have undesired effects on breathing. Conversely, specific surgical techniques designed to improve nasal breathing can have effects on appearance -- for better or for worse.

What causes nasal obstruction?

The most common causes are a deviated septum, enlarged turbinates, and middle vault narrowing. These factors can occur naturally, or as a consequence of trauma or prior rhinoplasty. They can occur alone or in combination, and can explain most nasal obstructive problems.

  • Deviated septum. The septum is a cartilaginous sheet that separates the right and left sides of the nose. The septum is rarely perfectly straight for anyone. A “deviation” is a bend of the septum. When the septum bends significantly to one side or the other, it can block the air passage on one or both sides, making it difficult to breathe.
  • Turbinates. The turbinates are the humidifiers of the nose. They are made mostly of nasal mucosa, so they periodically swell in response to the environment (i.e., allergies) or to position. To illustrate: if you lie on one side, you may notice that it becomes more difficult to breathe through the nostril on the “down” side. This is the effect of normal turbinate swelling. Sometimes, chronic enlargement of the turbinates can obstruct one or both sides. This condition may be treatable medically, but may require surgery for relief.
  • Middle vault narrowing or collapse. "Collapse" refers to weakness of the middle vault (sidewalls) of the nose, causing them to fall inward with deep inhalation. You may be familiar with adhesive strips worn on the nose by athletes to hold the nasal passages open. These devices help prevent collapse of the nasal sidewalls with inhalation.

What if the rhinoplasty is for purely cosmetic reasons?

Because of its location on the face, the nose is a very important cosmetic structure. Unlike many other areas, it is difficult to conceal undesired features.

What should an attractive nose look like? There really is no single answer to this question.

In the past, many plastic surgeons adhered to personal or popularized aesthetic ideals and allowed them to guide rhinoplasty procedures somewhat universally on their patients. Sometimes, this led to common appearance features among postsurgical patients. This is a trend that has fortunately been left to rest.

The modern rhinoplasty specialist goes through comprehensive exam with the patient to understand his/her personal aesthetic. One of the most important skills for the rhinoplasty surgeon is the ability to listen.

The nose is viewed not only alone, but in relationship to the shape and size of the rest of the face. The nose should share the characteristics of the face and accentuate them to create harmony. Ethnicity is a major consideration nowadays. Aesthetics may be enhanced while still retaining the natural beauty associated with a given culture or race. Rhinoplasty specialists are far more adept today at facial analysis, and are probably more skeptical of unrealistic desired changes of patients.

More than any other plastic surgery procedure, we are aware of the limitations of rhinoplasty surgery and the problems caused when these limits are exceeded.

How can a patient be confident in a surgeon's approach to cosmetic changes?

While the trend definitely favors a customized approach, there are certain aesthetic ideals that are still relevant as guidelines to the plastic surgeon.

The laws of proportionality, which have guided painters and sculptors for ages, still provide basic principles. Consequently, there are several relatively common concerns that plastic surgeons address -- a bump on the bridge of the nose, asymmetries, size discrepancies, etc.

What should a patient look for in his/her surgeon during the consultation process?

Look for someone who works with all aspects of the nose, either as a board-certified plastic surgeon or otolaryngologist (ENT), whether you're looking for cosmetic or functional rhinoplasty.

Make sure that rhinoplasty is a priority in their practice. You should be able to trust the staff and the facility.

Ask if you will be sedated or under general anesthesia. Ask about the surgeon's revisionary rate. Even among the best surgeons, you should expect between 5 and 7 percent.

For any of these questions, your surgeon should be open and forthcoming, not insulted.

What should patients keep in mind?

Consider your expectations. Televisions shows often reveal patients' postoperative photos  as if they were taken one day after the procedure. It takes time to achieve results; it doesn't happen when the bandages come off.

Bringing in pictures from magazines can help patients determine what they believe is attractive. However, direct comparisons can be detrimental, especially when there's little to no similarity between the facial structures. Ethnicity plays a huge role. We can't and shouldn't apply a Caucasian standard to everyone.

We want to work with patients to provide a nose that fits the face. One size does not fit all.

Learn more about rhinoplasty at Duke

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